NURS-170 EXAM 2 CORRECT 100%
List five major factors that affect sensory function. - ANSWER 1. Developmental level
2. Culture
3. Illness and medication
4. Stress
5. Personality and lifestyle
How does sensory deprivation occur? - ANSWER Sensory deprivation occurs when
there is a
deficiency of meaningful stimuli in the person's
environment
What are the signs of sensory deprivation? - ANSWER 1. Irritability
2. Confusion
3. Reduced attention span
4. Drowsiness
5. Depression
6. Preoccupation with somatic complaints
7. Delusions
8. Hallucinations
How does sensory overload occur? - ANSWER Sensory overload develops when either
environmental or internal stimuli—or a combination of both— exceed a higher level than
the client's sensory system
can effectively process.
Identify signs of sensory overload - ANSWER 1. Irritability
2. Confusion
3. Reduced attention span
4. Decreased problem-solving ability
5. Drowsiness
6. Muscle tension
7. Anxiety
8. Inability to concentrate
9. Decreased ability to perform tasks
10. Restlessness
11. Disorientation
Identify factors that may impair sense of taste - ANSWER 1. Impaired smell
2. Xerostomia
3. Upper respiratory tract infections
4. Smoking
5. Vitamin B12 or zince deficiency
6. Injury to the mouth, nose, or head
,7. Medications
How is the sense of smell triggered? - ANSWER The sense of smell is triggered when
chemoreceptors in the upper nasal cavities detect vaporized chemicals.
What areas of the body have the greatest number of tactile receptors? - ANSWER
Hands and face
What is the difference between myopia and
hyperopia - ANSWER Myopia (Nearsightedness) is the ability to see close objects well,
but not distant objects
Hyperopia (Farsightedness) is the ability to see distant objects well, but not near objects
What is the difference between conduction deafness
and nerve deafness? - ANSWER Conduction deafness is caused by problems affecting
any structure that transmits vibrations. These structures are in the outer and middle ear.
Nerve deafness is caused by damage to cranial
nerve VIII or the receptors in the cochlea.
Identify areas you should assess for a client with
known or suspected sensory alterations. - ANSWER 1. Factors affecting sensory
perception
2. Mental status
3. Level of consciousness
4. Recent changes in sensory stimulation
5. Use of sensory aids
6. Patient's environment
7. The support network
8. Focused examination of vision, hearing, taste, smell, touch, and balance
Identify at least two ways that you can assess vision
and hearing deficits at the bedside. - ANSWER Vision assessments. Have the client
read a newspaper, menu, or other printed matter and observe the client for squinting.
To assess distance, you might have the client identify someone or an object across the
room.
Hearing assessments. Observe conversations,
perform the whisper test
Identify safety measures that may be used with
clients with visual impairment - ANSWER • Place eyeglasses within easy reach.
• Make sure eyeglasses are clean, in good repair, and of the proper prescription.
, • Provide sufficient light, but avoid glare by using
soft, diffuse lighting.
• When outdoors, provide sunglasses or visors or
hats with brims.
• A client with significant impairment should be
evaluated for ability to drive.
Identify safety measures that may be used with
clients with hearing impairment. - ANSWER • If the client has a hearing aid, check to
make sure that it is working properly, the batteries are functional, and the sound is
adjusted to a comfortable level for the client.
• Blinking lights can be installed that alert the person to an incoming call or the ring of a
doorbell.
• Security alarms and smoke detectors with light
notification are also available.
- Make sure call light is within reach
What are the major concerns associated with loss of
smell and taste? - ANSWER Loss of the sense of smell diminishes taste and
denies the client the pleasure of enjoying food.
Without the gustatory sense, a client may eat less and be at risk for nutritional deficits
and weight loss. Safety issues (e.g., inability to smell smoke) are also a concern when
the client cannot smell.
What safety measures should be taught to a client
with tactile impairment? - ANSWER Use a bath thermometer to monitor water
temperature and prevent burns.
Change positions frequently to relieve pressure on bony prominences.
Use properly fitting shoes and socks.
Immediately report signs of circulatory impairment (e.g., declining motor function, cool
temperature, gray-blue coloration).
Inspect the client daily for open areas, cut, abrasions, or areas of redness.
How can you best assist a client who is confused? - ANSWER The confused client
requires nursing care that promotes reorientation. Numerous techniques are possible,
including the following:
List five major factors that affect sensory function. - ANSWER 1. Developmental level
2. Culture
3. Illness and medication
4. Stress
5. Personality and lifestyle
How does sensory deprivation occur? - ANSWER Sensory deprivation occurs when
there is a
deficiency of meaningful stimuli in the person's
environment
What are the signs of sensory deprivation? - ANSWER 1. Irritability
2. Confusion
3. Reduced attention span
4. Drowsiness
5. Depression
6. Preoccupation with somatic complaints
7. Delusions
8. Hallucinations
How does sensory overload occur? - ANSWER Sensory overload develops when either
environmental or internal stimuli—or a combination of both— exceed a higher level than
the client's sensory system
can effectively process.
Identify signs of sensory overload - ANSWER 1. Irritability
2. Confusion
3. Reduced attention span
4. Decreased problem-solving ability
5. Drowsiness
6. Muscle tension
7. Anxiety
8. Inability to concentrate
9. Decreased ability to perform tasks
10. Restlessness
11. Disorientation
Identify factors that may impair sense of taste - ANSWER 1. Impaired smell
2. Xerostomia
3. Upper respiratory tract infections
4. Smoking
5. Vitamin B12 or zince deficiency
6. Injury to the mouth, nose, or head
,7. Medications
How is the sense of smell triggered? - ANSWER The sense of smell is triggered when
chemoreceptors in the upper nasal cavities detect vaporized chemicals.
What areas of the body have the greatest number of tactile receptors? - ANSWER
Hands and face
What is the difference between myopia and
hyperopia - ANSWER Myopia (Nearsightedness) is the ability to see close objects well,
but not distant objects
Hyperopia (Farsightedness) is the ability to see distant objects well, but not near objects
What is the difference between conduction deafness
and nerve deafness? - ANSWER Conduction deafness is caused by problems affecting
any structure that transmits vibrations. These structures are in the outer and middle ear.
Nerve deafness is caused by damage to cranial
nerve VIII or the receptors in the cochlea.
Identify areas you should assess for a client with
known or suspected sensory alterations. - ANSWER 1. Factors affecting sensory
perception
2. Mental status
3. Level of consciousness
4. Recent changes in sensory stimulation
5. Use of sensory aids
6. Patient's environment
7. The support network
8. Focused examination of vision, hearing, taste, smell, touch, and balance
Identify at least two ways that you can assess vision
and hearing deficits at the bedside. - ANSWER Vision assessments. Have the client
read a newspaper, menu, or other printed matter and observe the client for squinting.
To assess distance, you might have the client identify someone or an object across the
room.
Hearing assessments. Observe conversations,
perform the whisper test
Identify safety measures that may be used with
clients with visual impairment - ANSWER • Place eyeglasses within easy reach.
• Make sure eyeglasses are clean, in good repair, and of the proper prescription.
, • Provide sufficient light, but avoid glare by using
soft, diffuse lighting.
• When outdoors, provide sunglasses or visors or
hats with brims.
• A client with significant impairment should be
evaluated for ability to drive.
Identify safety measures that may be used with
clients with hearing impairment. - ANSWER • If the client has a hearing aid, check to
make sure that it is working properly, the batteries are functional, and the sound is
adjusted to a comfortable level for the client.
• Blinking lights can be installed that alert the person to an incoming call or the ring of a
doorbell.
• Security alarms and smoke detectors with light
notification are also available.
- Make sure call light is within reach
What are the major concerns associated with loss of
smell and taste? - ANSWER Loss of the sense of smell diminishes taste and
denies the client the pleasure of enjoying food.
Without the gustatory sense, a client may eat less and be at risk for nutritional deficits
and weight loss. Safety issues (e.g., inability to smell smoke) are also a concern when
the client cannot smell.
What safety measures should be taught to a client
with tactile impairment? - ANSWER Use a bath thermometer to monitor water
temperature and prevent burns.
Change positions frequently to relieve pressure on bony prominences.
Use properly fitting shoes and socks.
Immediately report signs of circulatory impairment (e.g., declining motor function, cool
temperature, gray-blue coloration).
Inspect the client daily for open areas, cut, abrasions, or areas of redness.
How can you best assist a client who is confused? - ANSWER The confused client
requires nursing care that promotes reorientation. Numerous techniques are possible,
including the following:
